Chiropractors know almost nothing about child health

There are plenty of things we don’t know about health and illness. Sure, we know a lot more than we did fifty or a hundred years ago—but every day, still, I have questions that aren’t yet answered. I read a dozen or so journals each month. (I know. Nerd.) Each one has at least ten or so good quality studies—good, solid experiments to determine the best way to treat something, or basic science investigations to really understand what’s going on in the body. Heady stuff. And there are always more questions!

A question was posed to me this week: can chiropractic treatments help with scoliosis? My first thought was: probably not. I mean, I’ve never run across a study of chiropractic in my journals that shows effectiveness for scoliosis. Still, I wondered—what about the chiropractic journals? They have their own literature. Why not take a look?

I looked. And I am appalled. There is nothing—nothing, not a shred of evidence—that chiropractic can help scoliosis. One trial has been published involving all of six pediatric patients. That’s it? These are people who routinely treat children, who routinely treat back problems, and who are giving people the impression that they can help with scoliosis. And they’ve barely even studied it!

OK, maybe that was an isolated thing. So I dug more. I ran across a series of three published reports, all in established chiropractic journals, that together have reviewed the entire chiropractic published literature on pediatric care. Keep in mind, this is chiropractors themselves, reviewing their own knowledge base.

The first review, published in 2005, is titled Assessing the evidence for the use of chiropractic manipulation in paediatric health conditions: A systematic review. Chiropractors Gotlib and Rupert of the Canadian Chiropractic Association searched the entire biomedical literature, looking at everything that had been published using every database imaginable, to find all articles relevant to children. Their “inclusion criteria” were quite broad—they looked for any study involving children in a therapeutic setting that was published in a peer reviewed journal or reported at a conference, or any relevant systematic review. They found 166 published reports, almost all of which were “descriptive studies”—the lowest kind of evidence, where an author describes what was seen or done, without any corroboration or experimentation that what was done was effective. As for high-quality evidence, through 2003 only NINE randomized trials in children of chiropractic care for any pediatric health condition had been published. One was only a feasibility study that didn’t report results; one was on nursemaid’s elbow, which isn’t treated with chiropractic spine manipulation. Of the remaining seven studies: four showed no effect on asthma, bedwetting, colic, and jet lag; and three showed benefits in asthma, bedwetting, and colic. The total number enrolled in all 9 clinical studies was 590 children. The authors concluded:

“Health claims made by practitioners regarding the application of chiropractic manipulation as a health care intervention for paediatric health conditions are, for the most part, supported by low levels of scientific evidence.”

The same authors compiled a second review in 2008, to catch any studies published from January 2004 thru June 2007. They used the same exhaustive search, and the same broad criteria. They found ONE additional randomized trial—which was, actually, only a feasibility study involving six children with scoliosis. Their conclusion:

“There has been no substantive shift in this body of knowledge during the past 3 1/2 years. The health claims made by chiropractors with respect to the application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence.”

OK, this is looking bad. Real bad. Is anyone actually even trying to study children to figure out if chiropractic works, and when to use it?

A second group of authors picked up the baton, publishing their own thorough review in June 2012, specifically to see what new trials concerning children had appeared. There was quite an uptick in publications—from the four year span since the last review, from 2007 through 2011, sixteen studies were published about children, looking at a total of 1980 kids. About 500 kids a year were actually enrolled in clinical studies. It is a step in the right direction. However, many of the studies were poorly designed and difficult to interpret, according to the chiropractors who wrote the review. And ironically, there have been ZERO published studies, ever, looking critically for genuine evidence that Spinal Manipulative Therapy helps children with back pain. These authors concluded:

“Further research is clearly required in this area of chiropractic health care, especially with respect to the clinical effectiveness of SMT on pediatric back pain.”

I am glad that the chiropractors who compiled these three reviews have expressed their need for better pediatric studies. They’ve illustrated that their own profession has neglected children. They have essentially no evidence that any of their treatments work for any pediatric condition. However, at the rate they’re going, the tiny dribble of studies being published isn’t going to come close to a decent, reliable body of literature any time soon. A single issue of Pediatrics contains far more studies looking at far more children than the entire accumulated published experience of the entire chiropractic profession.

A caveat: these reviews of the chiropractic literature included all publications through the end of 2011. It is possible that 2012 saw an explosion of pediatric studies. I’d love to hear that, if it’s true. I don’t have subscriptions to these chiropractic journals, and don’t have the ability to completely review their 2012 literature myself.

Chiropractic professionals need to decide: Is treating children part of our practice? If so, they should insist on quality information to guide their practice to effectively help pediatric patients. Until they have that knowledge, they ought to tell parents that, honestly, they have no idea what they’re doing.

Mencken doesn’t dissappoint– incisive as always. I don’t think though that he’s entirely fair in putting all the blame on Dr Still. It was David Daniel Palmer who founded chiropractic and insisted that all disease is caused by invisible “subluxations.”

Where Dr. Still’s osteopathy has essentially merged into mainstream, science-based medicine, chiropractic is still largely clinging to Palmer’s odd and disproven guesses about how the body works.

Really? Why do you think most parents bring their children to Chiropractors? Do you think they confide in us first? It is mainly because they could not get the answers through their MD and they were at their wits end trying to find help for their child. Doctors with all of their studies could not even begin to help the child. Who did they search out? Someone that offered help. Do we have countless studies of biased literature and studies about treating pediatric children for specific condition? No we don’t. Yet, parents bring their children in and amazingly see results. The child finally had a sound night sleep after treatment. If we are such idiot’s, why are all of us still in business? Probably because we get results. Your last paragraph in your article should apply to all medical prefessionals because I bet most doctors have rarely read a study to treat a pediatric nor provide quality information. Good luck on your mission to destroy the kooky Chiropractor. I don’t think we will be going anywhere soon.

I will not deny that there is not an abundance of research in regards to chiropractic care and pediatrics but we are working on that as a profession. You are welcome to go to http://www.icpa4kids.com to see the research that is getting published. Chiropractic is a young profession compared to medicine and there are definately more medical providers over chiropractors. Therefore, the number of doctors that are able or willing to provide research and numbers are far less as a result. However, your comment ” they have no idea what they’re doing” is purely your judgement and you have no idea what level of education each of us have as well as the results we have with our young patients. Due to your article, you have persuaded me to became active and provide my own case studies and get involved in clinic bases studies as well. Thank you for the extra push and supporting chiropractic!

“Chiropractic professionals need to decide: Is treating children part of our practice? If so, they should insist on quality information to guide their practice to effectively help pediatric patients. Until they have that knowledge, they ought to tell parents that, honestly, they have no idea what they’re doing”

I would have to say I am from the Robert Mendelsohn school of thought when it comes to pediatrics. Keep away from medical doctors, give a fever three days to run its course and temperature is the bodies way of dealing with bacteria and virus. My 4 children have never had antibiotics the eldest is 26 the youngest is 6. Dont you think thats unusual, surely you view that as a good thing. It may be down to a difference in approach and do you think this phenomena should be explored further, bearing in mind the damage over prescribing of antibiotics is starting to have on this generation.

How would you manage a case of Otitis Media in a five year old boy and a case of colic in a ten week infant and what evidence would you base your decision on. These are two cases that presented at my practice recently and according to you I should have referred them out, so what would you have done? Then I will tell you what I did.

Dr. Baty, parents seek chiropractic care because they trust that chiropractors can help them. If practicing chiropractors were as honest as the chiropractors I’ve cited, they would inform parents that they have essentially no studies and no support for chiropractic treatment for pediatric patients. Then parents would be well-informed, and would decide what to do. In the long run, trust should be built on honesty.

I didn’t call chiropractors “idiot’s”. I am saying that there is a glaring lack of support for chiropractic care of children, and I’m calling on the chiropractic community to be honest about that and vigorously pursue pediatric research. Now it is up to your profession to decide to either 1) grown and learn; or 2) deny and stagnate.;

Marie made an unfounded claim about a lack of nutritional training for doctors. As a medical student I had entire courses (that means multiple classes in a series) devoted exclusively to nutrition, and nutrition played a major role in biochem, pathology, physiology, anatomy, embryology, phamacology– heck, almost every class was steeped in nutrition. Nutrition is a huge part of clinical rotations too, when we learn about managing both ordinary and parenteral nutrition for patients of different ages, some of whom have speific nutritional problem, or others at risk.

As a pediatrician, nutritional issues are a huge part of my practice, and there are many posts on this blog right here about nutrition issues.

If you want to look at the medical literature to see how much nutrition information there might be (comparing, say, to the amount of information on pediatric chiropractic care), you could step over to Pubmed and find over 265,000 citations when you MESH that one search term. That doesn’t even include millions of more citations if you care to look at individual micronutrients, etc.

Your contention that doctors don’t know about nutrition is flat out wrong.

Chiropractic is indeed a young profession– but the “mainstream” medical profession didn’t embrace a scientific method of understanding health and disease until maybe 100 years ago, approximately the same age as chiropractic. I am very glad to hear that at least some chiropractors will be looking towards objective scientific study to learn more about health and disease, and to guide their practice towards the best ways to help patients.

Richard: Robert Mendelsohn? A colorful character, he “opposed water fluoridation, immunization, coronary bypass surgery, licensing of nutritionists, and screening examinations to detect breast cancer.” He also died in 25 years ago. It’s ironic that you’ve chosen him as a guide in response to my post calling for contemporary research and expanding knowledge.

Over-prescribing of antibiotics is a huge problem, and one I’ve brought up several times on this blog. Fortunately, continued research is increasing our understanding of this phenomenon, and every major medical society is actively publishing guidelines to properly guide doctors towards the judicious use of these important medications. More work is to be done, and I agree too many quacky doctors continue to overprescribe.

The management of conditions like otitis media and “colic” (which is not actually a diagnosis, but a symptom) depends on the history and physical examination of the individual patient. From there, there is a huge amount of guidance from the medical literature on the best, evidence-based ways to proceed. For instance, the AAP’s guidance on the management of otitis has 136 solid references. Strong, reliable, and continuously studying and learning to improve care. I am calling on the chiropractic profession to emulate this approach.

I know you did not directly call us idiots. The title suggests it. Chiropractors Have Little Research to Back Up Pediatric Care would have been a better title. I do agree our profession needs to make better strides.

Here’s a wonderful article from the journal Chiropractic and Manual therapies, written by an Australian chiropractor and educator, Titled “Chiropractic at the crossroads, or are we just going around in circles,” it examines the struggle within the chiropractic community between ideology and science. Is chiropractic beholden and forever bound to the myths of Daniel David Palmer’s supernatural explanations, or should they be guided by natural, observable, testable theories?

The medical profession faced a similar choice. For hundreds of years, we were guided by the principles of “The four humors” and other dogma. I am sure that some physicians fought the tide of science, preferring to cling to long-held beliefs. Chiropractors have a similar choice to make.

Roy, the point I was making about Mendelsohm, was his main point was we over premedical childhood illness and most should be allowed run their natural course without medicine.

You recognize over prescription of antiobiotics is a problem and yet seem to be suggesting with the link that, antibiotics is they the way you would treat acute otitis media . This guidline is hardly conclusive evidence of a way to treat AOM and guarded with the statement “This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

that it did “not support the routine use of antibiotics for children up to 18 years with otitis media with effusion. The largest effects of antibiotics were seen in children treated continuously for four weeks and three months. Even when clear and relevant benefits of antibiotics have been demonstrated, these must be balanced against the potential adverse effects when making treatment decisions. Immediate adverse effects of antibiotics are common and the emergence of bacterial resistance has been causally linked to the widespread use of antibiotics for common conditions such as otitis media.

So what might one do when faced with a child in extreme pain, as there is a lack of evidence right across the board to support any intervention. What I always do is look at the anatomy to see if anything could be done mechanicly. The pain comes from a build of exudate in the middle ear, its similar to the pain divers feel when failing to equalize on descending too fast. To equalise experienced divers wiggle/crack their TMJ joint which opens the eustachian tube. This method can also help the middle ear to drain in acute cases of otitis media, bearing in mind the problems with antibiotics I would suggest this may be a preferable solution to the “evidence based” method you have suggested. Anecdotal yes, however I would claim success in 3 out of 4 cases. Having explained it as I have do you still thing I should have referred the boy to you for treatment with antibiotics.

And yes the chiropractic profession should be doing more research into these areas however at the moment “Back Pain” is the coin of the realm as far as the chiropractic politicians are concerned. I am just a clinician.

Richard, you’re quoting the Cochrane review for “Otitis media with effusion”, which is a different entity from “Acute otitis media.” The natural history, diagnosis, and treatment of these conditions are completely different. Conflating the two is an error that someone claiming to know how to treat these conditions shouldn’t make. This illustrates that a chiropractic education may not provide a good basis for evaluating and treating ear infections.

The link to the AAP statement on Acute otitis media does not suggest antibiotics as first line therapy for most cases of this condition. Perhaps you ought to read it before making that incorrect assumption.

I am glad you agree that that the chiropractic profession needs to actually study the treatment of these conditions. My contention is that study and publication and understanding ought to precede treatment, not the other way around.

Not sure I would agree when you say the natural history of the two are “completely different”. The question is when the effusion becomes infected.

Otitis media with effusion is when the fluid in the middle ear is not infected (OME) which frequently precedes the development of AOM. Acute otitis media is when fluid in the middle ear becomes infected with bacteria. These children often are quiet sick and in my experience parents don’t bring children with high fevers into my clinic .If they did I refer to what I said above, its recommendation 3 in your guideline, as Robert Mendelsohn advises give a fever 72 hours and see if it runs its course. Middle ear effusion is present in both otitis media with effusion and acute otitis media. I was not claiming to treat “Infections” I was explaining the anatomy as to how one might unblock the middle ear. Differentiating between the two is important for a medical doctor who might be going to prescribe antibiotics for the reasons stated in your guidelines.

“A major challenge for the practitioner is to discriminate between OME and AOM.17,18 OME is more common than AOM. OME may accompany viral upper respiratory infections, be a prelude to AOM, or be a sequela of AOM.19 When OME is identified mistakenly as AOM, antibacterial agents may be prescribed unnecessarily”

That is not what a chiropractor does.

You say “study and publication and understanding ought to precede treatment” however in the absence of conclusive evidence from either of our professions shouldn’t we go with our experience?

So how would you establish with certainty whether a bacterial infection was present before deciding whether to prescribe antibiotics and have you a better way than I suggested for relieving pressure in the middle ear that’s causing the child pain?

Distinguishing a bacterial ear infection requires a careful history and physical exam. If you’d like to learn to do this, I suggest you work with a pediatrician or ENT. It takes time and practice. Having never attended chiropractic school, I cannot comment on the ability or inability of your chiropractic instructors to teach diagnostic skills such as these.

However, since the original post was about the appalling lack of pediatric research in the chiropractic literature, I’m going to steer this conversation back in that direction. PubMed is a free service from the National Library of Medicine that searches the entire published literature– including, I believe, all of the established chiropractic journals (I’m not 100% certain of that– perhaps one of our chiropractic commenters can correct me on this point if I am wrong. I am admittedly not familiar with all of their journals.) You can search yourself — this link will show you just about all of the chiropractic information that’s been published in their literature about otitis media. What you’ll find is, essentially, zero: one “feasibility study” from 1999 showing that chiropractic manipulation could be studied; and one “retrospective” review showing that children with ear infections improved when given chiropractic care in addition to medical care. No surprise there, we know ear infections get better. That study was also limited by relying on parental report of improvement rather than any sort of standardized, objective diagnosis. It also involved only 46 non-randomized children. That’s it, that’s their objective knowledge base.

The care of otitis media by chiropractors is an excellent example — they do what they seem to feel works, or whatever they’ve been taught works, but there’s been no attempt at objectively figuring out if it works at all. Medical doctors certainly don’t have all of the answers, and there is plenty more to learn. That’s why we study and experiment and try to determine objective data. That’s why there are hundreds of medical journals publishing thousands of studies a year. Chiropractors could use science to study their skills and how best to apply them. Why don’t they?

We are ignorant on how to do this or at least I am. I was taught very little in regards to performing a study and having it published. Although it was taught, I did not realize the importance. Now that I am in practice, I don’t know how anyone would have the time to do it or learn to do it. We tend to learn what works while in practice. When people are satisfied, they refer others in. That is what I base my knowledge and treatments from. I feel that even if we did do elaborate studies, we would still be ridiculed for our findings.

Actually, I am also curious as to why certain MD’s do a study? I noticed you mentioned “we” as in MD’s perform studies to get objective data to better treat patients. Not all MD’s do this. So why do certain MD’s decide to do this? I would assume that there would be some greater motivation other than providing data to the whole profession.

Dr. Baty, some MDs spend a lot of time doing clinical research, others “bench” or basic science research– they’re often, but not always, affiliated with medical schools. Other physicians spend more of their time seeing patients. Some do both. These are different career paths, I suppose mostly chosen based on personal interest. Those of us who do little research on our own read the journals and meet with the research-types at meetings to discuss things and stay in touch with each other.

I am not surprised to learn that there isn’t much discussion of academic matters in chiropractic school, or that it sounds like many or most of your mentors and teachers were not themselves researchers. Changing chiropractic from a dogma- and “know-how” based practice system to one based on study and research will take significant generational and fundamental change. While perusing the chiropractic literature to prepare this post, I found many chiropractors calling for just such a change, in papers like this one. Are they in the majority? Do most chiropractors want more for their patients, or are they more interested in the status quo and honoring traditional tenets? That’s for you and your profession to decide.

I am saddened to see your sentence, “I feel that even if we did do elaborate studies, we would still be ridiculed for our findings.” You may well be right– there is bad blood between chiropractors and the medical profession, and I agree that many MDs would be skeptical of chiropractic science. This transformation may take generations. I think you will find that more and more physicians would be happy to work with chiropractors who embraced science and were sincerely eager to join the traditions of physicians, dentists, podiatrists, and the many other healers that make up the “mainstream” health care system. The choice begins with you.

Peace, and best wishes to you for the insight and fortitude to do the right thing.

A brief quote, the ending of the chiropractic paper I linked to in the above comment: “…there is currently little evidence to inform chiropractic care of children. The chiropractic profession needs to be responsible for moving forward the evidence-base from which to inform chiropractic clinical practice for children. We suspect that no other profession will do this for us!”

Hear, hear.

That article, by the way, was part of a series on chiropractic and children’s health.

Roy, in response to your last point. You cant compare the resources available to the medical profession and chiropractic.Chiropractors do study and experiment and try to determine objective data, thats what we are talking about here. However the profession has decided to focus its research resources in one particular area musculoskeletal conditions so I dont think its fair to say the chiropractic profession is not using science to study their skills and how best to apply them. I agree there is much room for improvement.

What I disagree with is the title of your post “Chiropractors know almost nothing about child health”. Why do you think you know any more than I do about ” children s health”, I have done a masters in Health Promotion at a mainstream university, head of the department was a brilliant medical man the late Professor Theodore MacDonald. However I accept my lack of medical knowledge may have contributed to my children never having had medicine of any kind and having strong immune systems. They hardly ever miss a day of school, eat healthily and taken regular exercise, no DS’s in our house. My question to you, is this what one might describe as healthy children? and desirable to observe in children generally.

The knowledge and experience I have has contributed greatly to the obvious health and wellbeing of my children and if this phenomena is repeated by the children of all chiropractors dont you think this would be desirable and perhaps we have something to teach the medical guys who have over prescribed antibiotics to children over the last thirty years with the irreversible consequences to the effectiveness of antibiotics to treat serious illness.

You are assessing me as a medical practitioner, I am not and have never claimed to be, I maintain joint function if that relieves pressure on the middle ear great, if it does not there is something else causing the problem. In fact, I have discussed the evidence for treating Otitis Media with an old school friend Ray Clark who is the leading ENT specialist in the UK http://www.amazon.co.uk/Ear-Nose-Throat-at-Glance/dp/144433087X and the medical evidence is not convincing.

You state; “the care of otitis media by chiropractors is an excellent example — they do what they seem to feel works, or whatever they’ve been taught works” – Isnt that exactly what you do in the absence of convincing clinical evidence, you make clinical judgments based on what you know, if your evidence was convincing parents would not bring their children to see me. Now you know something else that could work for your patients or are you saying it is not possible to have children who have never had antibiotics or relieve pressure on the middle ear by manipulating the TMJ joint?

Very interesting conversation. What do you learn in chiropractic school anyway? I’ve never gone to a chiropractor myself, although I have come across some chiropractors, one of whom wanted to reset his own dog’s dislocated hip (no) and one of whom was advising people not to vaccinate their children (Uhh…. WHAT???).

Richard, I’m not sure what you’re saying. Because you’re not a medical person, you don’t need to study the effects of your intervention on ears, even though you’re claiming to be able to treat or prevent ear problems?

You say that as a profession chiropractors are concentrating their resources on musculoskeletal concerns. There have been zero studies, ever, trying to determine if chiropractic manipulative therapy helps children with back pain.

Your comments about the health of your own children are not germane to whether chiropractors are adequately studying their interventions and the effect they have on children.

You seem to be saying that manipulation of the TMJ (really, just TMJ– the J already stands for “Joint”) relieves pressure in the middle ear. Fine. How about some evidence that this is true? It would be trivially easy to study. You wouldn’t even need to know how to examine an ear. Buy a tympanometer, do the study of middle ear pressures before and after your intervention(s). Heck, if a tympanometer is too expensive buy one of these for $35: http://www.amazon.com/EarCheck-1124-Earcheck-Middle-Monitor/dp/B003VDEKAE/

I do not think it’s lack of money, or lack of time or opportunity. It’s just a different mindset. I want evidence for what I do. I believe chiropractors should, too.

By the way: if you do want to pursue such a study, you’ll want to include a control group using sham chiropractic or no intervention at all. Middle ear effusions improve without therapy; what you’d like to show is that they improve more quickly with chiropractic care.

Roy I have not claimed to “treat or “prevent” ear problems. No more that advising people with Gout to wear large Crocs will bring untold relief. An experienced diver could help someone with pressure in the middle ear, I dont think this is exclusively a chiropractic issue, I am sure there are lots of medical doctors who dive.

My comment about the health of my children are not related to whether chiropractors are studying their interventions, its related to the title of your post “Chiropractors know almost nothing about child health”

Funny, I had contacted a local health center with a view to doing a study in 2010, we spoke about Otitis Media or Asthma. Thats why I spoke to Ray Clarke about ear infections. Unfortunately I was diagnosed with stage three rectal cancer which has taken up a lot of my time during the last two years. Now there is a conversation we could have about treatment and evidence. To be fair the doctors were always honest with me, when they were punting in the dark and I am in remission now so I have no complaints. After I finished chemotherapy in May I had serious peripheral neuropathy could not walk 100 hundred meters no sensation in my hands and was told there was noting more they could do for me, I was free of cancer, go home. I am in the process of writing a book on how I got from there to competing in one of the hardest Marathons of all on the Great Wall of China in May 2013. My “mindset” thats how.

Whoever Blake Baty is he sure is defensive and reads a lot into what the article is stating. And I can’t help but point out yes, he does seem to have a recurring theme with spelling and grammatical errors. It’s not looking at these facts in a vacuum are any indication of somebody’s overall character, but taken all together it kind of proves the original poster’s point. Chiropractors are NOT medical professionals. Period. And in reading Mr. Baty’s own postings here, he’s clearly not very professional NOR is he that interested in the well-being of children. He is clearly only here to defend a strange practice uneducated people embrace. Combine that with the appalling lack of access to medical care, we have a perfect storm in our culture for desperate parents to bring their kids to somebody like HIM. What I find almost humorous is that there’s actually more evidence to support prayer healing scoliosis than “chiropractic” (and whoever invented that adjective clearly didn’t know the rules of the English language, either). Keep on talking, Mr. Baty. You’re showing the true colors of those in your “profession.” Bye the way, I’m a doctor, too, but don’t go around putting “Dr.” in front of my name constantly the way chiropractors feel the need to do. And my doctorate is in English… which makes me just as qualified to diagnose disease as you are.

Mr. Cory
Try reading the whole thread. I support Dr. Roy. Our proffesion needs more science based treatment. For the record, I don’t treat children. I just didn’t like the name of the article. Please feel free to point out any grammatical errors. Dr. Baty